Health inspection·August 31, 2025

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the confidentiality of each resident's personal and protected health information. The P&P indicated all information contained in the resident's medical record is confidential and may only be released by the written consent of the resident or legal representative, consistent with state laws and regulations, a discharged resident may obtain photocopies of his records by providing the facility with at least 15 calendar days advance notice of such request. The facility will transmit copies within 15 calendar days after receiving the written request. Event ID: Facility ID: 055070 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure, a resident who was a Full Code (a medical term indicating a person's consent to receive all possible life-saving measures), received basic life support ([BLS], care healthcare professionals provide to anyone whose heart stops beating suddenly), including cardiopulmonary resuscitation ([CPR] an emergency life-saving procedure to restart a person's heart [chest compressions)]) per the resident's Physician Order for Life Sustaining Treatment ([POLST] a form that contains written medical orders for healthcare professionals regarding the residents wishes for specific medical treatments that can or cannot be done during life threatening emergencies where the resident is incapacitated) and facility's policy and procedure, for one of one sampled resident (Resident 1).2. Ensure registered nurse (RN) 1 honored and followed Resident 1's POLST dated [DATE], and provided the resident with CPR/BLS when Resident 1 was found unresponsive (does not react to verbal or physical cues) and without a pulse (heartbeat) on [DATE] at approximately 9:45 a.m. 3. Implement the facility policy and procedure (P&P) titled, Emergency Procedure-Cardiopulmonary Resuscitation, dated 2001, which indicated, if a resident is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: instruct a staff member to activate the emergency response system (code) and call 911. These failures resulted in RN 1 not administering CPR and not calling 911 when Resident 1 was found unresponsive and pulseless on [DATE]. Resident 1 expired on [DATE]. These failures placed 47 other residents in the facility, who have a Full Code status, at risk of not receiving life saving measures when needed.Based on interview and record review, the facility failed to: 1. Ensure, a resident who was a Full Code (a medical term indicating a person's consent to receive all possible life-saving measures), received basic life support ([BLS], care healthcare professionals provide to anyone whose heart stops beating suddenly), including cardiopulmonary resuscitation ([CPR] an emergency life-saving procedure to restart a person's heart [chest compressions)]) per the resident's Physician Order for Life Sustaining Treatment ([POLST] a form that contains written medical orders for healthcare professionals regarding the residents wishes for specific medical treatments that can or cannot be done during life threatening emergencies where the resident is incapacitated) and facility's policy and procedure, for one of one sampled resident (Resident 1).2. Ensure registered nurse (RN) 1 honored and followed Resident 1's POLST dated [DATE], and provided the resident with CPR/BLS when Resident 1 was found unresponsive (does not react to verbal or physical cues) and without a pulse (heartbeat) on [DATE] at approximately 9:45 a.m. 3. Implement the facility policy and procedure (P&P) titled, Emergency Procedure-Cardiopulmonary Resuscitation, dated 2001, which indicated, if a resident is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: instruct a staff member to activate the emergency response system (code) and call 911. These failures resulted in RN 1 not administering CPR and not calling 911 when Resident 1 was found unresponsive and pulseless on [DATE]. Resident 1 expired on [DATE]. These failures placed 47 other residents in the facility, who have a Full Code status, at risk of not receiving life saving measures when needed. On [DATE] at 7:10 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Director of Nursing (DON), Administrator (ADM) and consultant Administrator due to the facility's failure to provide basic life support (BLS) to Resident 1, including immediate initiation of CPR. On [DATE], the facility submitted an acceptable Immediate Jeopardy Removal Plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055070 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few (IJRP). After onsite verification of IJRP implementation through observation, interview, and record reviews, the IJ was removed on [DATE] at 2:43 p.m., in the presence of the ADM, the DON and the consultant ADM. The IJRP included the following: 1. On [DATE], the DON provided in-service to Registered Nurse (RN 1) regarding POLST policy and procedure, honoring and following the Residents' POLST (if Full Code, start CPR and immediately call 911). 2. On [DATE], the DON and the Director of Staff Development (DSD) provided an in-service to licensed nurses and the Clinical Team members of the Inter-Disciplinary ([IDT] the residents health care team) composed of the Assistant Director of Nursing (ADON), Quality Assurance (QA) Nurse, Minimum Data Set (MDS)/Resident Assessment Coordinator, Social Service Designee (SSD), Activity Director, regarding honoring and following the Residents' POLST. 3. On [DATE], the DSD started providing in-service training to the Certified Nursing Assistants (CNAs) on procedures in administering CPR and calling 911. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), chronic heart failure (heart disorder that causes the heart to not pump blood effectively) and ischemic heart disease (condition where poor blood flow causes heart tissue damage or death). During a review of Resident 1's History and Physical (H&P) dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's POLST, dated [DATE], the POLST indicated if Resident 1 had no pulse and was not breathing to attempt resuscitation/CPR. The form indicated the POLST was discussed with Resident 1, who had capacity to understand. The form was signed and dated by Physician (MD) 2 and Resident 1 on [DATE].During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated [DATE], the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was moderately impaired and he had the ability to understand and be understood by others. The MDS indicated Resident 1 was fully dependent on staff (requiring two or more-person assistance to complete the activity) for toilet hygiene and putting on and taking off footwear, required partial assistance (helper does less than half the effort) for eating, oral hygiene and personal hygiene. During a review of Resident 1's IDT Meeting Document dated [DATE], the IDT Meeting Document indicated Resident 1 had the capacity to understand and represented himself during the meeting. The IDT Meeting Document indicated Resident 1 wished to be a Full Code. During a review of Resident 1's Nurses Progress Notes, documented by Licensed Vocational Nurse ( LVN) 1, dated [DATE], the Nurses Progress Notes indicated during medication pass on [DATE] at 9:45 a.m., LVN 1 could not obtain Resident 1's vital signs (measurements of the body's basic functions such as heart beat and breathing), RN 1 called to bedside to assess Resident 1. During a review of Resident 1's Nurses Progress Notes dated [DATE], the Nurses Progress Notes indicated when RN 1 assessed Resident 1, RN 1 found Resident 1's skin warm to the touch with no obtainable vital signs (no pulse and no breathing). The Nurses Progress Notes indicated RN 1 notified MD 1 who pronounced Resident 1 as expired. During a review of Resident 1's Physician's Discharge summary, dated [DATE], the Physician's Discharge Summary indicated Resident 1's date of death was [DATE]. During a review of Resident 1's Final Autopsy Report, dated [DATE], the Final Autopsy Report indicated Resident 1's date of death was [DATE] and the immediate cause of death was an acute myocardial infarct ( [heart attack] when blood flow to the heart muscle is blocked) likely associated with COPD induced hypoxia (lack of oxygen [gas needed to sustain life] in the body's tissues). During an interview on [DATE] at 3:27 p.m., RN 1 stated LVN 1 called her to Resident 1's bedside on [DATE], around 9:45 a.m. when LVN 1 found Resident 1 unresponsive. RN 1 stated Resident 1's skin was warm to the touch, he was not responsive, his chest did not rise and fall (indicating Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055070 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 1 was not breathing) and did not have any detectable pulse. RN 1 stated she was CPR certified but she did not attempt CPR and instructed LVN 1 not to perform CPR nor call 911 because she thought Resident 1's POLST indicated Do Not Resuscitate ([DNR] if a person's heart or breathing stops, the person wishes the doctors and nurses not to restart it by doing CPR). During an interview on [DATE] at 2:46 p.m., the DON stated when a resident is found unresponsive, staff should immediately check for a pulse, if the resident does not have a pulse, then immediately start chest compressions, call for help, and immediately call 911. The DON stated, if chest compressions and/or CPR was not initiated immediately after the heart stops beating, the chances of the resident's survival decreases and the risk of permanent brain damage or death increases. The DON stated the resident's POLST must be honored.During a telephone interview on [DATE] at 5:46 p.m., the Facility Medical Director (MD 3) stated the facility must honor the residents' wishes as indicated in their POLST. During a review of the facility's Policy & Procedure (P&P) titled, Emergency Procedure-Cardiopulmonary Resuscitation, dated 2001, the P&P indicated if a resident is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: instruct a staff member to activate the emergency response system (code) and call 911, instruct a staff member to retrieve the automatic external defibrillator (an external defibrillator is a machine that helps restart a person's heart if it suddenly stops or beats the wrong way), verify or instruct a staff member to verify DNR or code status of the individual, initiate the basic life support (BLS- compressions, airway, breathing) sequence of events. During a review of an online article titled, American Heart Association 2020, CPR and Emergency Cardiovascular (anything that has to do with the heart and blood vessels) Care Committee Guidelines, the article indicated, the adult basic life support algorithm (a process or set rules to be followed) for healthcare providers included verifying for scene safety, check for responsiveness, shout for nearby help, look for no breathing or only gasping and check pulse simultaneously (at the same time). The guidelines further indicated if there was no breathing, or only gasping, with no pulse, to immediately begin CPR and perform cycles of thirty chest compressions and two breaths.AHH CPR Guidelines During a review of an online article titled, How to Perform CPR - Adult CPR Steps the article indicated, to check the scene for safety, check the person for responsiveness/breathing, if the person does not respond and is not breathing or only gasping, call 911, get equipment, or tell someone to do so, kneel beside the person, and place them on their back on a firm, flat surface. The guidelines indicated to begin chest compressions 30 at a time, give two breaths and to continue the cycle of 30 chest compression and two breaths.www.redcross.org During a review of the facility's P&P titled, POLST/ Advanced directive, undated 2001, the P&P indicated the purpose of the P&P was to specify the form to be used by the facility in documenting resident's preferred intensity of care. The P&P indicated the facility will honor a resident's completed POLST form from the hospital if there is no change to it. The facility must review the POLST with the resident / responsible party and document that this is in the resident's medical records.During a review of the POLST (in general) form, the form indicated the following: 1. First follow these orders, then contact the Physician/Nurse Practitioner/Physician Assistant.2. A copy of the signed POLST form is a legally valid physician's order. Any section not completed implies full treatment for that section. Event ID: Facility ID: 055070 If continuation sheet Page 5 of 5